Provider Demographics
NPI:1407044001
Name:DICKSON, ELAINE BURGESS (PA)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:BURGESS
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:C
Other - Last Name:BURGESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1534 ELIZABETH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4516
Mailing Address - Country:US
Mailing Address - Phone:318-629-5002
Mailing Address - Fax:318-629-5020
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:STE 100
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101
Practice Address - Country:US
Practice Address - Phone:318-635-3052
Practice Address - Fax:318-632-6087
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5B103Medicare PIN
LAP00435047Medicare PIN
LA5B103P895Medicare PIN